1093988545 NPI number — GEOFFREY R. COUSINS, MD, PLLC

Table of content: (NPI 1093988545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093988545 NPI number — GEOFFREY R. COUSINS, MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEOFFREY R. COUSINS, MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093988545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4695
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25364-4695
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-720-2244
Provider Business Mailing Address Fax Number:
304-720-2245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 CHESTERFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304-1062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-720-2244
Provider Business Practice Location Address Fax Number:
304-720-2245
Provider Enumeration Date:
04/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COUSINS
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-720-2244

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  21957 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810011619 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002022475 . This is a "BC/BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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